Back to School Program Human Services Department

Human Services Department

Back to School Program
Dear Parent or Guardian,

With the last day of the school year just around the corner, we are already looking towards the first day of the next school year. The Department of Human Services annually provides assistance to qualifying families by providing school supplies, and other assistance to pruchase back to school nedessities.

If you or your household currently participates in the Town of Mansfield Fee Waiver Program, you automatically qualify for the Back to School Program and do not need to submit additional information with the attached application. If you do not participate in the Fee Waiver Program, eligibility requirements include the following:
- You and your household have been Mansfield residents for at least 3 months prior to the date of application (proof of residency due with application).
- You and your household meet the following income guidelines and Proof of income is required with the application. Income is based on ALL income earners in the home. Proof of income includes 6 weeks or pay stubs, your last Income Tax return, SSI or DSS income statements, etc.
If you would like to participate, please fill out the this application by:

August 1st, 2026

Applications can be submitted online, and mailed. Please mail in or drop off additional documentation at:

Human Services Department

303 Maple Rd.

Mansfield, CT 06268

They can also be placed in the secure lock box located outside of the entrance to the Human Services office or emailed to human.services@mansfieldct.org. Applicants will be contacted by August 7th, 2026 with additional program details.

Applications received after August 1ˢᵗ, 2025 may not be eligible for assistance. As this program relies on community donations with limited funding, item availabilty may vary from year to year. We will have supplies ready for distribution the 2nd week of August, and a date will be provided in your approval letter.

If you have any questions, please feel free to call The Mansfield Human Services Department at 860-429-3315.

Sincerely,

The Human Services Staff

Back to School Program Application

Human Services Department
Name of Parent or Guardian:
Phone
Format: (000) 000-0000.
Email
example@example.com
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Please check one of the following:
My current annual gross income from all sources is
Please enclose ALL of the following with this application:
- Proof of Residency. Applicants must reside in Mansfield for more than three months prior to the date of application.
- Three (3) most recent pay stubs for all income earners in the household.
- Copy of other sources of income (if applicable) i.e.: Social Security, Unemployment, Workman's Comp, SSDI, Veterans Benefits, SAGA, TANF, Child Support, etc.
- Additional considerations and factors you wish to be known in determining your eligibility.

CHILDREN RESIDING IN HOUSEHOLD ENTERING GRADES K-12 IN FALL OF 2025

Rows	Name	Relationship	Date of Birth	School & Grade in Fall 2025
1
2
3
4
5
6
7
8

Please indicate the items that you would like, with the # of each item.

We will do our best to supply what we can but cannot guarantee all items.
Pens:
Pencils:
Pencil Pouch:
Markers:
Crayons:
Colored Pencils:
Pocket Folders:
Erasers:
Wide ruled notebook:
College Ruled Notebook:
1/2 inch Binders
1 inch binders
Pencil Sharpener:
Please indicate store(s) preference for gift cards:
Please upload supporting documents

Cancelof
I hereby certify that the information supplied is accurate to the best of my ability: Applicant Signature
Date

MonthDayYear
Date
Mansfield Human Services I 303 Maple Road, Mansfield, CT 06268 I 860.429.3315 I mansfieldct.gov
Should be Empty:

Human Services Department

Back to School Program Application